Waiver Intake Form

Name of Workshop/Class (Please also specify if it’s Virtual.) *

Full Name *

Email *

Address

Street Address *

City *

State *

Country *

Postal code

Phone

Who referred you? *

Would you like to sign up for my monthly newsletter? *

Yes

No

If you're pregnant, how many weeks along are you?

Permission for Videography/Photography *

I understand that there may be videography and/or photography for purposes of filming the instructor and clips of the event..

I give permission to be included in such filming.

I take full responsibility for my health and safety as a participant in this class/workshop given by instructor/facilitator, Morgyn Danae. I will use proper judgment when participating. If I have any injuries or health concerns, I will alert the instructor/facilitator beforehand and get my doctor/health care provider’s approval before attending. The instructor/facilitator and owner of this facility are not responsible and are released from any liability for any injuries or accidents that may occur while I am participating. All of this information is true to the best of my knowledge. I release her/them from any liability as a result of instruction/facilitation. *

Yes

Waiver Signature *

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